If health care is broken, doctors and patients must ‘grasp the levers of change’ starting at the ballot box, advocate says

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Doctors have a chance to influence democracy when they help their patients register to vote, whether in this election season or in the future, said the physician founder of an organization devoted to voting.

Alister Martin, MD, MPP, started Vot-ER in 2019 as a hospital pilot program in Massachusetts. Since then, it has grown into a national nonprofit, nonpartisan organization dedicated to supplying voter registration assistance and election reminders. The word and the work has spread, with more than 50,000 physicians and other clinicians helping their patients register to vote at approximately 700 participating sites, and with more than 400 partnerships.

The efforts continue as National Voter Registration Day approaches on Sept. 17 and the nation gears up for the 2024 presidential election. Martin, an emergency medicine specialist, sat down with Medical Economics to explain the origins of the organization and the importance of citizens casting ballots.

This transcript has been edited for length and clarity.

Medical Economics: By way of introduction, can you talk about your own education, training and experience in medicine and in voting?

Alister Martin, MD, MPP
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Alister Martin, MD, MPP: I started medical school back at Harvard Medical School, and really came in bright-eyed bushy-tailed and hopeful about the future of my career in medicine. And I would say that, you know, right around third year of medical school, which is what many of the listeners, potential viewers, remember, going into the wards for the first time for their clinical rotations, was my first sort dose of reality in regards to the medical system in this country. For me, it was my first time being on the side of health care providers delivering care. What I saw was a system that let some of our most vulnerable patients down, kind of a system that discharged patients who were homeless to the street when it was four degrees outside at 4 a.m. the morning, where patients were charged more for an aspirin because they didn't have insurance than those who did have insurance. I saw these repetitive episodes where the health care system let folks down. So that is what triggered me to leave medicine, actually, for a couple of years, went to the Harvard Kennedy School of Government for two years, and there began to learn, gee, if the health care system is the thing that is broken, that is need of treatment, there are these ways in which we can begin to grasp the levers of change to help to create a more fair, more just health care system. And it was there that I began to really wake into this idea of power of civic engagement, the importance of voting, and the way that we as health care providers, nurses, physicians, social workers and on, have immense power to actually change things within our health care system, make them more fair for our patients.

Medical Economics: Based on those experiences early on in your medical career and your public policy career, what made you want to start Vot-ER?

Alister Martin, MD, MPP: I actually was taking care of a patient in my third year as an emergency room resident at Boston Children's Hospital and I had this young woman who came in and who was homeless. She came with her two children, and she and her two children needed emergency shelter for the night. And luckily, at the time, we still practiced in a state that had a right to shelter law for families here in Massachusetts, and so I knew that. I called the social worker, I said, look, we've got this young woman and her two kids, I don't feel comfortable sending them to the adult shelter, I don't think that's a safe option. What are our other alternatives? And the social worker said, you know what? No problem, we can get them into a state-run hotel or motel, single room occupancy shelter. All they need is some proof of residence, that they are a Massachusetts resident. And unfortunately, in this case, the patient was not a Massachusetts resident. She had just moved maybe two or three months prior to escape an abusive situation with the father of her kids. It was a real conundrum because we needed to get this person into shelter, but she didn't have proof of residence in the state of Massachusetts. And so the social worker said, well, there's this one thing that we can do. And I said, well, what's that? She said, we can help her register to vote in this state of Massachusetts, and that voter registration will count as proof of residence in the state of Massachusetts, and we can get her state-run shelter in this emergency capacity. And so we did that. When I went back to talk to the patient about the prospect of registering to vote, the patient said to me something I'll never forget. She said, doctor, I didn't know I could, no one has ever asked me that before. For me, that really began the wheels spinning in my mind around – well, geez, is it possible that many of my patients feel exactly like this patient and are just sort of waiting on the outskirts of our democracy for an invitation to get involved? And that was really the spark that initiated the beginning of Vote-ER, back in 2018. And then in 2019 we started our first Vot-ER institutional partnership that was right here at Mass General Hospital in the ER helping people register vote through a kiosk, actually.

Medical Economics: In terms of logistics, in practical terms, you had mentioned about setting up a kiosk at the hospital where you worked.

Alister Martin, MD, MPP: That's right. After that experience with this patient, I began to realize that it wasn't just this patient, right? We have over 72 million Americans in this country who are eligible to register to vote, but who are not registered to vote. And when you ask these folks, why aren't you registered? The vast majority say the same thing. They say, well, no one's ever asked me. And so I began thinking, well, could we use the downtime that a patient is waiting in a health care setting to do the process of voter registration? And working here at the Harvard Medical School and Mass General Hospital, we set up the first large-scale implementation that had to have three specific measures to be successful right up front, and we still hold true to these factors to begin with today. And that is, one, it cannot be interruptive. We cannot have a system that is making it difficult for patients to actually get the care they need. The second is, it has to be nonpartisan. We have a commitment to nonpartisanship that is fierce at Vot-ER mostly because, at the end of the day, we're working with so many hospitals, health care systems, health centers that have to abide by really strict 501(c)(3) guidance around voter registration in (nonprofit) health care settings. And the last is the optionality of this. We have to make this optional for patients. This can never be something that's mandatory or contingent on any care being delivered. And those three principles to this day still course through the bloodstream of Vot-ER.

Where we are now, happily, we're at 700 hospitals, health care systems, medical schools. They don't use kiosks anymore, though. What they use now is a badge that clips onto the back of your hospital ID. It's got a QR code on it, which can help your patient register to vote right there. And then a lanyard that says “ready to vote?” on it. So, when I go in for my shift in the ER, patients will often ask me, hey, doc, why does your lanyard say “vote” on it? And I'll say, well, it says vote on it because I want you to take 30 seconds now and scan this QR code and check your voter registration. We have a number of other interventions, posters, discharge paperwork. We even work with many community health centers to send text messages to their patients about the importance of voting. And all of this is really undergirded by a new movement called the civic health movement. It's really connecting this piece of physical health to civic health. The best example of that is actually the American Medical Association, which just two years ago acknowledged voting as a social determinant of health. This is just one of many interventions now that you're seeing across the country helping to tie these two things together.